TRANSMISSIBLE DISEASES, VACCINATIONS
& THE ORAL HEALTHCARE WORKER
Presentation By:
Robin Evans, AnnMarie Teerlink, Raj Obhi, Vivian Vuong
Human Herpes Viruses (HHV)








HHV 1: Herpes Simplex Virus 1
(HSV-1)
HHV 2: Herpes Simplex Virus 2
(HSV-2)
HHV 3: Varicella-Zoster Virus (VZV)
HHV 4: Epstein-Barr Virus (EBV)
HHV 5: Cytomegalovirus (CMV)
HHV 6: Herpes Lymphotrophic Virus
HHV 7: Roseolovirus
HHV 8: Kaposi’s Sarcoma
https://globalmedicaldiscovery.com/key-scientific-articles/chromosomally-integrated-human-herpesvirus-6questions-and-answers/
Herpes Simplex Virus 1 and 2: Background
Information

HSV-1:
o
o
o
Mouth & lips
Can also cause genital
herpes
Primary Infection:
o
o
http://en.wikipedia.org/wiki/Herpes_labialis#mediaviewer/File:Herpes(PHIL_1573_lores).jpg
Recurrent Infection:
o

Herpetic
Gingivostomatitis
Herpes Labialis
HSV-2:
o
o
Genital herpes
Considered a STD
http://www.pemcincinnati.com/blog/briefs-approach-patient-sore-throat/herpetic-gingivostomatitis/
HSV-1 and HSV-2: Background Information

Direct contact &
Fomites:
o Saliva
o Herpetic Lesions
o Semen
o Fluid in female
genital tract
o Gingival Sulcular
Fluid
Mode of Transmission
http://www.wikihow.com/Prevent-Cold-Sores
HSV-1 and HSV-2: Background Information

Symptoms are triggered by:
http://candyraine.blogspot.com
Sun
 Fever
 Menstruation
 Emotional stress
 Weakened immune system
 Illness


Contagious even when asymptomatic
http://www.investwithalex.com/avoid-stress/
HSV-1 and HSV-2: Background Information

Symptoms of HSV-1:
 Fever
 Sore
throat
 Swollen lymph nodes in the neck
 Tingling and burning around mouth or nose
 Usually
 Small,
a few days before the blisters appear
painful blisters filled with fluid
 Around
lips or edge of mouth
HSV-1 and HSV-2: Background Information

Symptoms of HSV-2:
Fever
 Muscle aches
 Headache
 Painful urination
 Swollen lymph glands in the groin area
 Women: vaginal discharge
 Tingling sensation in genitals, buttocks, and thighs
 Small, red blisters and open sores in genital region


May or may not be painful
HSV-1 and HSV-2: Implications for Dental
Hygiene Practice
Herpetic Whitlow
http://stanfordmedicine25.stanford.edu/the25/hand.html
Ocular Herpes
Herpetic Whitlow


Distal phalanx of fingers
Torn cuticle in finger or minor skin abrasion
 Contact
with lips or saliva
 Can self-infect



Cross-infection to others
More frequently in HCP than in general public
Standard precautions!
Ocular Herpes/ Conjunctivitis


Transfer from finger to eye
Can Cause:
 Pain
 Photophobia
 Blurred
vision
 Tearing
 Redness
http://reference.medscape.com/features/slideshow/foreign-body-sensation
HSV-1 and HSV-2: Vaccines & Medications


No vaccine available
Some treatments available:
 Can
lessen severity and frequency of outbreaks
 Help prevent infected people from spreading the virus
http://buy-6-famciclovir-pharmacy-6.weebly.com
http://valacyclovirhcl.weebly.com
http://www.acyclovirnoprescription.org
HSV-1 and HSV-2: Prevention

Do NOT treat unless lesion is crusted over
Prodromal Stage

Early Redness of
Skin
Small
Blisters/Vesicles
Swelling/Edema
Standard Precautions!
Open Ulcers
Dry Crusts/Scabs
Complete Healing
Hepatitis Virus
Hepatitis A
 Hepatitis B
 Hepatitis C
 Hepatitis D
 Hepatitis E
 Hepatitis G

http://www.webmd.com/hepatitis/ss/slideshow-hepatitis-overview
Hepatitis B: Background Information

Epidemiology:
 Responsible
for 60-80% of liver cancer
 ~1.4 million people in the U.S. may have chronic
hepatitis B infection
 2009: ~38,000 people became infected w/ hepatitis
B
 ~2,000 to 4,000 people die each year in the U.S. from
cirrhosis or liver cancer caused by HBV
Hepatitis B: Background Information
Acute
Symptoms
Loss of appetite
Chronic
Symptoms
Liver cancer
Fatigue
Diarrhea and Vomiting
Liver damage
Pain in muscles, joints, and
stomach
May have jaundice
Death
Hepatitis B: Background Information
Contact with
blood or other
body fluids
(breaks in skin)
Fomites (Virus
can live for up
to 7 days on
contaminated
object)
Parenteral
(getting stuck
with a used
needle)
MODE OF
TRANSMISSION
Sharing
needles with
injecting drugs
Perinatal
Unprotected
sex
Hepatitis B: Implications for Dental
Hygiene Practice


HBV Vaccine
Pre-vaccination era (1975-1989):


http://livercancerconnect.org/the-hepatitis-b-vaccine
Occupational risk among GDPs was
2-3x greater than in the general
population
Now:
 Major concern, but transmission
is rare
 Standard precautions (1985)
 Routine vaccinations for
dental workers (1987)
Hepatitis B: Vaccines
•
•
Vaccine available
for all ages
Currently Available
Vaccines:
•
•
•
•
Recombivax HB
Engerix-B
Comvax
Twinrix
Dose #1:
Dose #2:
Dose #3:
• 0 months
• 1 month
after Dose
#1
• 6 months
after Dose
#1
Anti-HBs
Serologic
Test:
• 1-2 months
after Dose
#3
Hepatitis B: Vaccines and Immunity

Antibody level and immunity against Hepatitis B
virus infection among general dental practitioners
 Authors:
Scully
Stefano Petti, Giuseppe Messano, Crispian
Hepatitis B: Vaccines and Immunity

Italian general dental practitioners (GDP)
vaccination and immunity rates
 88%
of GDPs were vaccinated
 83% were immune
 5% were vaccinated but NOT immune

Anti-HBs Serologic Testing is important!
Legal and Ethical Considerations
Hepatitis & HHV





CDC recommendations for standard precautions
OSHA mandated Hepatitis B vaccine
Sterilization and Disinfection
Effective hand washing
Work Restrictions Guidelines
HSV 1: Evaluate need to restrict from care of patients at
high risk until all lesions heal
 HSV 2: No work restriction
 Herpetic Whitlow: Restrict from patient contact and contact
with patient’s environment until all lesions heal
 Conjunctivitis: Restrict from client contact and contact with
client environment until no discharge

Measles, Mumps and Rubella




Viral diseases that are vaccinepreventable (MMR)
At risk non-immune pregnant
women and unborn child
Incidence significantly reduced with
vaccine in U.S.
Vaccination is said to be linked with
causing Autism
 Parents are not compliant with
vaccine schedules
 Posing a social conflict in schools
putting other families at risk
http://www.microbiologyonline.org.uk/about-microbiology/microbes-and-the-human-body/vaccination
MMR Vaccine


Vaccine given 12-15
months of age and again
at age 4-6
Infants 6 to 11 months old
should have at least one
dose before travelling
abroad
http://www.cdc.gov/vaccinesafety/Vaccines/MMR/
Measles (Rubeola)
Highly contagious respiratory
infection
• Virus replicates in cells of oropharynx & lungs
Transmitted via droplet nuclei
(aerosols)
Common cold symptoms followed by
a rash
• Initiates at mouth & face then extends to
body
http://www.cdc.gov/measles/about/photos.html
Can cause spontaneous abortion
during 1st trimester
Measles Statistics of Severity

20 million worldwide, 164,000 deaths annually

2/1000 children will die from measles

1/20 children will get pneumonia


1/1000 will have permanent brain damage or
deafness from encephalitis
Incidence is rare and sporadic in U.S. and
countries with high vaccination rates



Visitors from other countries directly cause
outbreaks
In 2014: 603 cases & 20 outbreaks
22 states including CA
http://www.cdc.gov/measles/about/overview.html
http://www.cdc.gov/measles/importation-infographic.html
Dental Considerations


Review health history
Extraoral and Intraoral exam
 Koplik Spots on buccal mucosa & palate
Aerosols should be avoided
Reappointing the contagious patient
 Earliest 4 days after rash onset
 If patient has a fever, do not do elective procedures
90% of non-vaccinated individuals exposed will get the
disease
 Think of your other patients and staff members
http://www.nlm.nih.gov/medlineplus/ency/imagepages/2558.htm



Koplik Spots


Observed 3 days after infection
Full rash appears 1-2 days later
http://www.hxbenefit.com/kopliks-spots.html
http://www.nlm.nih.gov/medlineplus/ency/imagepages/2558.htm
Mumps





Viral infection transmitted via
droplets
Parotitis: swelling of salivary glands
In adult males: swelling of the testes
Vaccination reduced incidence by
98%
Now uncommon in the U.S.
http://www.cdc.gov/mumps/about/mumps-facts.html
Mumps



Patients with swollen glands need to be isolated for
5 days after onset
20% of patients do not experience symptoms and
can still infect others
50% of patients have non-specific symptoms
 Malaise
 Fever
 Myalgia

Use standard precautions
http://www.compliancesigns.com/NHE-18542.shtml
Rubella (German measles)
3 day measles



Contagious viral infection
Transmission through droplets – sneezing and
coughing
Causes severe defects to unborn baby
 Heart
defects
 Cataracts
 Mental retardation

Congenital Rubella Syndrome (CRS)
Dental Considerations
Measles, Mumps and Rubella

Use standard precautions

Head and neck exam


Reappoint patients with
swollen glands or fever
Encourage them to seek
medical attention
http://www.dentalcare.com/en-US/dental-education/continuingeducation/ce337/ce337.aspx?ModuleName=coursecontent&PartID=2&SectionID=5
Tetanus, Diptheria, and Pertussis
TdaP
• Tetanus Diptheria aCellular
Pertussis
• Adolescents & Adults
Expectant
Mothers,close friends
& Family
DTaP
• Diptheria Tetanus aCellular
Pertussis
• Infants in 5 series
Infants & Children
• Tetanus Diptheria
• Booster every 10 years
Health Care Workers,
Adults, Adolescents
Td
Tetanus
“Lockjaw”




Toxin from bacteria Clostridium tetani in soil, dust
and animal feces
Enters the body from break in skin
Not spread person to person
Symptoms:
 Muscle
stiffness - jaw
 Seizures
 Difficulty swallowing


1 in 5 who get it will die from it
No cure - symptoms are managed only
http://mdisbase.com/article/tetanus-7-clinical-pearls
Diptheria




Bacterial infection Corynebacterium diphtheriae that
reproduces on the mucous membranes of the
oropharynx.
Transmitted via airborne droplets, contaminated
surfaces and personal items
Symptoms
 Swollen glands (enlarged lymph nodes) in your
neck
 Cold symptoms: fever, chills or malaise
 A thick, gray membrane covering your throat
and tonsils
 Difficulty breathing or rapid breathing
Infectious for up to 6 weeks even if no longer
showing symptoms
http://www.historyofvaccines.org/content/diphtheria-1
Pertussis



Respiratory illness caused by bacteria
Bordatella pertussis
Transmission via droplets – coughing
Initial Symptoms
 Cold
Symptoms: Low grade fever, runny
nose

1-2 weeks later cough develops
 Coughing
breathing
fits that can cause difficult
http://www.cdc.gov/pertussis/about/causes-transmission.html
Pertussis
Acellular pertussis vaccine use in risk groups (adolescents, pregnant women, newborns and healthcare
workers): A Review of evidences and recommendations
Authors: Bechini, Tiscione, Boccalini,Levi, Bonanni
Immunity weakens 5 years after last vaccine
Children age 11 or older are at high risk
Current Vaccine Schedule needs improvement
Anti-bodies passed from vaccinated mother are short lived in the infant
Baby needs to be vaccinated in 5 series
Close contacts need to be vaccinated
Healthcare workers that work in neo-natal units or with children less than 12 years old
Boosters are needed sooner than 10 years
Td Booster insufficient
Bechini A, Tiscione E, Boccalini S, Levi M, Bonanni P. Acellular pertussis vaccine use in risk groups (adolescents, pregnant women, newborns and healthcare workers): A Review of evidences and
recommendations.Vaccine [Internet]. 2012 June 15 [cited 2014 Jul 13]; 30 (2012) 5179– 5190 Available from: http://www.sciencedirect.com/science/article/pii/S0264410X12008444
Dental Considerations
Diptheria, Tetanus and Pertussis
REAPPOINT symptomatic
patients
Standard precautions must
ALWAYS be practiced
Take the time to DISINFECT
properly in between patients
MAINTAIN your vaccinations
http://en.wikipedia.org/wiki/Diphtheria
Legal and Ethical Considerations

DO NO HARM

Avoid skipping Head and Neck Examination & Health Assessment

Do not push treatment on an infected patient

You, staff and their families and other patients are at risk!

Do not work when you are contagious

Maintain your own vaccinations

Avoid cutting corners for the sake of your schedule & pocketbook
http://www.zazzle.com/peace_love_dental_hygiene_poster-228198477429159648
Influenza


Is a viral infection of the respiratory system.
Can be potentially deadly for those who are
at a higher risk.
http://www.pillbox123.com/new-flu-rx-under-fda-review/flu-virus/
Transmission on Influenza



The flu virus is highly
contagious.
Direct inhalation of air
droplets in coughs and
sneezes of infected
individual.
Can also be spread
through coming into
contact with surfaces
touched by infected
individual.
http://wonderopolis.org/wonder/why-do-you-sneeze/
Symptoms







Fever
Fatigue
Weakness
Aching muscles
Nasal congestion
Chills and sweats
Cough
http://health.syr.edu/Education/flu.html
Prevention/Care after exposure




Flu shot
Building antibodies
Rest and fluids
Antiviral medications – in severe cases.
http://www.flu.gov/prevention-vaccination/vaccination/
Tuberculosis (TB)



Highly contagious
bacterial infection
of the lungs.
Mycobacterium
tuberculosis
Active vs. Latent
http://www.webmd.com/a-to-z-guides/understanding-tuberculosis-basics
Transmission of TB


Can be transmitted through tiny droplets released
into the air from sneezing or coughing.
Can be very dangerous to those who have a
weakened immune system (HIV positive Pt’s)
https://ethnomed.org/clinical/tuberculosis/firland/latent-tb-faqs
Symptoms







Persistent cough
Bloody mucus
Chest pain
Fatigue
Fever
Night sweats
Chills
http://www.dnaindia.com/health/report-smoking-increases-risk-of-tuberculosisrecurrence-study-1971896
Prevention/Care after exposure






Getting tested
Avoiding contact
Wear a mask
Isolation
Follow proper medication
protocol
Proper room ventilation
http://en.wikipedia.org/wiki/Mantoux_test
Legal and Ethical

Vaccination against influenza to
help diminish risk of transmitting
disease to our patients.





Influenza vaccination for health
care workers- Author: Music, T.
Applying proper prevention
methods
Proper infection control
Being able to identify certain risk
factors for infected patients.
Knowing when it is appropriate to
provide treatment to patients who
are infected.
What is HIV/AIDS and How is it
transmitted?

HIV: Precursor to AIDS
 Integrated
into the hosts DNA;
replication
 Host immunocompromised =
Opportunistic Infections
 Transmission: Contact w/
blood and body fluids
 *No
Cure
 Antiretroviral
Treatment (ART)
– sustain body’s defenses;
prolong onset of AIDS
http://aids.gov/hiv-aids-basics/hiv-aids-101/what-is-hiv-aids/
Lesions Indicative of HIV/AIDS
Oral Candidiasis

Pseudomembranous Candidiasis

Thrush

Most common lesions seen in HIV+
http://www.hiv.va.gov/provider/image-library/oral.asp?post=1&slide=327
ORAL HAIRY LEUKOPLAKIA
http://hardinmd.lib.uiowa.edu/cdc/6061.html
Lesions Indicative of HIV/AIDS
NECROTIZING ULCERATIVE
GINGIVITIS
KAPOSI’S SARCOMA
http://gr.dentistbd.com/necrotizing-ulcerative-gingivitis-ppt.html
http://upload.wikimedia.org/wikipedia/commons/d/d5/Kaposi%E2%8
0%99s_sarcoma_intraoral_AIDS_072_lores.jpg
Lesions Indicative of HIV/AIDS
ANGULAR
CHELITIS
http://www.dermnetnz.org/site-age-specific/angular-cheilitis.html
Safety and Risk of Healthcare Workers

CDC 2011: 57 HCW
infected w/ HIV at work


86% exposure needle stick
injury
Power Scaling Devices:
Less time
 Less needle stick injuries
 *No evidence of aerosol
transmission

http://lionsdentalsupply.com/Dental_Ultrasoinic_Scalers.html
Implications for Care
PROCESS OF DH Care
Health
Problems
&
Social
Stigmas
Patient Interview/Health History:
1. Shake Hands-1ST Impression-Professionalism
2. Be sensitive and AWARE:
-Drug Regimen:
-If tested: Ask if HIV +/-Hospitalization Hx
-High risk sex/drug use
4. Be supportive, reaffirm patient
-Importance of accurate health info
http://kellyandari.wordpress.com/page/3/
Dental Hygiene Treatment
IF:
 Unusual lesions/nodules
 Signs of necrotizing
periodontal disease
Then:
Refer to MD or dentist




DH visits every 2-3
months
Consider pt. dexterity
when prescribing
treatment
Suggest prescription of
0.12% chlorhexidine
mouth rinse
Work as a team
Patient Education

EMPHASIZE:
 Good oral hygiene-> Controllable factors in
health; empower them
 HIV/AIDS pts: increased caries risk
 Decreased pH & buffering
capacity of saliva (Hegde 2013)
 Avoid “acid baths”; eat healthfully:
 Neutralize pH
 Connection of oral health to systemic health
http://www.pinterest.com/ofallondental/aboutmonticello-dental-your-dentist-in-ofallon-mi/
Ebola Virus (Ebola Hemorrhagic Fever)



A deadly infectious
disease-source unknown.
Bats? Incubation 2-21
days
Transmission: Direct: blood
and body fluids(urine, saliva,
sweat, vomit, feces, semen,
breast milk); contaminated
needles.
HCW at highest risk- contact
with body fluids; no
outbreaks in US
http://www.nbcnews.com/storyline/ebola-virus-outbreak/bioethicist-ebolatreatment-west-troubling-bad-science-n178026
Ebola Virus
(Ebola Hemorrhagic Fever)

Precautions for HCW:
 Isolate
suspected person
 PAPR or N95 respirator
 Impermeable boot covers, apron, full coverage of skin
 Disposables
 Designated areas for PPE donning and doffing
 Education & training
 Long shifts for HCW overseeing pt.  less exposure
Legal and Ethical Considerations in Dental Health
Care of HIV/AIDS Patients
Ethical Principles


COMPLEMENTARITY: TREAT
OTHERS HOW YOU WOULD WANT TO BE
TREATED


NONMALEFICENCE : PREVENT
HARM

BENEFICIENCE:
OUR DUTY
IS TO PROMOTE GOOD

JUSTICE:
JUST &
FAIR TREATMENT FOR ALL

IT IS OUR ETHICAL OBLIGATION TO TREAT
CLIENTS WITH DISEASE

Surveyed dentists in Pakistan:
HIV/AIDS knowledge and
infection control
63% poor infection control;
correlated with knowledge of
HIV/AIDS
Less than 25% of dentists said
would treat someone with
HIV/AIDS (Khail 2013)
References
Bechini A, Tiscione E, Boccalini S, Levi M, Bonanni P. Acellular pertussis vaccine use in risk groups (adolescents, pregnant women, newborns and
healthcare workers): A Review of evidences and recommendations.Vaccine [Internet]. 2012 June 15 [cited 2014 Jul 13]; 30 (2012) 5179–
5190 Available from: http://www.sciencedirect.com/science/article/pii/S0264410X12008444
CDC: Vaccines and Immunizations [Internet]. Page last updated: [2010 Mar 7; cited 2014 Oct 13]; [about 1 screen.] Available from:
http://www.cdc.gov/measles/vaccination.html
CDC: Vaccine Safety: Concerns About Autism [Internet]. Page last updated: [2014 Aug 25 ; cited 2014 Oct 15]; [about 1 screen.] Available
from: http://www.cdc.gov/vaccinesafety/Concerns/Autism/Index.html
CDC: Measles (rubeola)[Internet]. Page last updated: [2013 Sep 12; cited 2014 Oct 15]; [about 6 screens.] Available from:
http://www.cdc.gov/measles/about/overview.html
CDC: Mumps [Internet]. Page last updated: [2010 Mar 14 ; cited 2014 Oct 13]; [about 5 screens.] Available from:
http://www.cdc.gov/mumps/about/disease-overview.html
CDC: Pertussis (whooping cough) [Internet]. Page last updated: [updated 2013 Dec 13; cited 2014 Sep 28]; [about 6 screens.] Available from:
http://www.cdc.gov/pertussis/index.html
CDC: Rubella [Internet]. Page last updated: [2009 May 29; cited 2014 Oct 13]; [about 5 screens.] Available from:
http://www.cdc.gov/rubella/about/index.htm
References
CDC: Tetanus [Internet]. Page last updated: [ 2014 Nov 10; cited 2014 Nov 14]; [about 1 screen.] Available from:
http://www.cdc.gov/vaccines/vpd-vac/tetanus/fs-parents.html
Coughing image. Dnaindia.com [internet image].[cited 2014 Nov 20] Available from: http://www.dnaindia.com/health/report-smokingincreases-risk-of-tuberculosis-recurrence-study-1971896
Darby ML, Walsh MM. Dental hygiene theory and practice. 4th ed. St. Louis, Missouri: Elsevier; c2015. 101-110 p.
Darby, ML, Walsh MM. Dental Hygiene Theory and Practice. 4th ed. St. Louis (MO): Mosby Elsevier; 2015. p. 861-871
Dentalcare.com: The Intraoral and Extraoral Exam [Internet] . Page last updated; [2012 Aug 8]; cited 2014 Nov 12]; [1 screen] Available
from: http://www.dentalcare.com/en-US/dental-education/continuingeducation/ce337/ce337.aspx?ModuleName=coursecontent&PartID=2&SectionID=5
Flu Vaccine Image. Flu.gov [internet image].[cited 2014 Nov 20] Available from: http://www.flu.gov/prevention-vaccination/vaccination/
Flu Virus image. Pill Box123 [internet image].[cited 2014 Nov 20] Available from: http://www.pillbox123.com/new-flu-rx-under-fdareview/flu-virus/
Hegde MN, Malhotra A, Hegde ND. Salivary pH and buffering capacity in early and late human immunodeficiency virus infection. Dent Res
J [Internet]. 2013 Nov-Dec [cited 2014 July 12]; 10(6):772-776. Available from:http://www.ncbi.nlm.nih.gov/pubmed/24379866
References
Hepatitis B Vaccine. [Internet]. MedlinePlus. 2012 Feb 2 [updated 2012 Mar 15; cited 2014 Oct 3]. Available from:
http://www.nlm.nih.gov/medlineplus/druginfo/meds/a607014.html
Hepatitis B Vaccination. [Internet]. CDC. 2014 Oct 3 [updated 2014 Feb 3; cited 2014 Oct 3]. Available from:
http://www.cdc.gov/vaccines/vpd-vac/hepB/default.htm
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GAME TIME
• Mask
• Goggles
Don PPE • Gloves
CLEAN
WINNER
• Use Wipes to Disinfect “The Unit”
• Cleanest Unit Wins a Special Prize!
You have 45 Seconds!!!